﻿<%@ Page Language="C#" AutoEventWireup="true" CodeFile="CRMPatientEdit.aspx.cs" Inherits="CRMPatientEdit" %>

<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">

<html xmlns="http://www.w3.org/1999/xhtml">
<head runat="server">
    <title></title>
</head>
<body>
    <form id="form1" runat="server">
    <div>
    <p style="text-align:center"><img src="images/retroGW.jpg" width="200" alt="logo" /></p><br />
        <asp:Panel ID="pnLocked" runat="server" Visible="false">
        Patient is currently locked. Click <asp:LinkButton ID="lnkReturn" runat="server" Text="here"></asp:LinkButton> to return to list.
    </asp:Panel>
    <asp:Panel ID="pnPatientInfo" runat="server" Visible="true">
        <br />
        <b>Quick Options:</b><br />
        Outcome:  <asp:DropDownList ID="ddlItemOptions" runat="server" AppendDataBoundItems="true">
                        <asp:ListItem Text="Select Item" Value="" Selected="True"></asp:ListItem>
                    </asp:DropDownList>
        <br />
        Note: <asp:TextBox ID="txtNote" runat="server" MaxLength="200"></asp:TextBox>
        <br />
        <asp:CheckBox ID="chkCloseCase" runat="server" Text="Close Case" />
        <asp:Button ID="btnSaveStatus" runat="server" Text="Save Status" />
        <hr />
        <br /><br />
        <b>History:</b><br />
        <asp:GridView ID="gvHistory" runat="server" AutoGenerateColumns="false">
            <Columns>
                <asp:BoundField DataField="DateUpdated" HeaderText="Date" />
                <asp:BoundField DataField="Status" HeaderText="Status" />
                <asp:BoundField DataField="UserName" HeaderText="User" />
                <asp:BoundField DataField="Notes" HeaderText="Notes" />
            </Columns>
        </asp:GridView>
        <hr />
        <br />
        <br />
        <b>Patient Info:</b>
        <br />
        <table>
            <tr>
                <td>First Name</td>
                <td><asp:TextBox ID="txtPatientFirstName" runat="server"></asp:TextBox></td>
            </tr>
            <tr>
                <td>Last Name</td>
                <td><asp:TextBox ID="txtPatientLastName" runat="server"></asp:TextBox></td>
            </tr>
            <tr>
                <td>Phone (Home)</td>
                <td><asp:TextBox ID="txtPatientPhoneHome" runat="server"></asp:TextBox></td>
            </tr>
            <tr>
                <td>Phone (Cell)</td>
                <td><asp:TextBox ID="txtPhoneCell" runat="server"></asp:TextBox></td>
            </tr>
            <tr>
                <td>Email Address</td>
                <td><asp:TextBox ID="txtEmailAddress" runat="server"></asp:TextBox></td>
            </tr>
            <tr>
                <td>OK to SMS?</td>
                <td><asp:CheckBox ID="chkSMS" runat="server" /></td>
            </tr>
            <tr>
                <td>OK to Email?</td>
                <td><asp:CheckBox ID="chkEmail" runat="server" /></td>
            </tr>
            <tr>
                <td>Address(1)</td>
                <td><asp:TextBox ID="txtPatientAddress1" runat="server" /></td>
            </tr>
            <tr>
                <td>Address(2)</td>
                <td><asp:TextBox ID="txtPatientAddress2" runat="server" /></td>
            </tr>
            <tr>
                <td>City</td>
                <td><asp:TextBox ID="txtPatientCity" runat="server" /></td>
            </tr>
            <tr>
                <td>State</td>
                <td>
                    <asp:DropDownList ID="ddlPatientState" runat="server">

                    </asp:DropDownList>
                </td>
            </tr>
            <tr>
                <td>Zip</td>
                <td>
                    <asp:TextBox ID="txtPatientZip" runat="server"></asp:TextBox>
                </td>
            </tr>
            <tr>
                <td><b>Medical Info</b></td>
                <td>
                </td>
            </tr>
            <tr>
                <td>Red Card Number</td>
                <td>
                    <asp:TextBox ID="txtPrescriptionNumber" runat="server"></asp:TextBox>
                </td>
            </tr>
            <tr>
                <td>Red Card Expiration</td>
                <td>
                    <asp:Calendar ID="clPrescriptionExpiration" runat="server" Visible="false"></asp:Calendar>
                    <asp:TextBox ID="txtPrescriptionExpiration" runat="server"></asp:TextBox>
                    <asp:ImageButton ID="imgCalendarPrescription" runat="server" ImageUrl="~/images/calendaricon.gif" />
                    <asp:HiddenField ID="hidOriginalExpiration" runat="server" />
                </td>
            </tr>
            <tr>
                <td>Birth Date</td>
                <td>
                    <asp:TextBox ID="txtDOB" runat="server"></asp:TextBox>
                </td>
            </tr>
            <tr>
                <td>Drivers License Number</td>
                <td>
                    <asp:TextBox ID="txtDriversLicenseNum" runat="server"></asp:TextBox>
                </td>
            </tr>
        </table>
        <asp:Button ID="btnSaveInfo" runat="server" Text="Save" />
    </asp:Panel>
    </div>
    </form>
</body>
</html>
